BACKGROUND/RATIONALE:
CART-CL is a clinical software application that is integrated in the VA's electronic health record (EHR) and supports a national data repository and quality improvement program. From 2004-2009, CART-CL was developed and implemented in 77 VA cath labs. The goal of this project was to measure variations in implementation of CART-CL across VA cath labs, and identify facilitators and barriers to successful implementation.


OBJECTIVE(S):
Our objectives were to: (1) describe the rate and degree of implementation of CART-CL in the 77 VA cath labs; and (2) using quantitative techniques, identify the key barriers to complete adoption and ongoing use of the system.

METHODS:
The rate and degree of implementation of CART-CL, from first contact with a site through technical installation and then clinical adoption, was assessed via the CART-CL tracking database and by comparing procedure entries in CART-CL with site case logs at three time points. Clinical adoption by site was described at each time as full (>90% concordance), partial (1-90%), or none (0%). To assess facilitators and barriers, we surveyed clinical champions at each of the sites using a structured, web-based survey.

FINDINGS/RESULTS:
Installation of CART-CL has taken place over the last five years and continues as new cath labs are initiated in the VA system. Between June, 2004-May, 2007, 59 sites (77%) had either fully or partially adopted CART-CL; by April, 2009, 74 sites (96%) had fully (71%; 52) or partially adopted (29%; 21) CART-CL. Technical installation took a median of 3 4.2 months, while the time to clinical adoption, defined as the time from installation completion to active use, took a median of 1 7.6 months.
Survey responses were obtained from 64 sites (83% of sites). Sites felt integration of CART within the VA EHR was extremely important (74%; 47). The majority agreed that CART would improve current processes (80%; 51). The majority also believed CART was strategically important to VA quality improvement (76%; 49). Among the top facilitators noted were CART's integration within the VA EHR, future research potential using CART, and the desire to improve quality. Respondents cited contentment with current processes, concern regarding staff resources, and lack of interfacing with proprietary hemodynamic systems as top barriers.

IMPACT:
CART represents a successful nationwide health IT implementation. Understanding key facilitators and barriers in the installation and adoption of CART-CL in VA cath labs may help to guide and improve the implementation process of future health IT-based quality improvement and patient safety initiatives.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Maddox TM, Ho PM, Tsai TT, Wang TY, Li S, Peng SA, Wiviott SD, Masoudi FA, Rumsfeld JS. Clopidogrel use and hospital quality in medically managed patients with non-ST-segment-elevation myocardial infarction. Circulation. Cardiovascular quality and outcomes. 2012 Jul 1; 5(4):523-31. [view]
2. Box TL, McDonell M, Helfrich CD, Jesse RL, Fihn SD, Rumsfeld JS. Strategies from a nationwide health information technology implementation: the VA CART story. Journal of general internal medicine. 2010 Jan 1; 25 Suppl 1:72-6. [view]

DRA: Health Systems Science
DRE: none
Keywords: Cardiac procedures, Cardiovasc’r disease, Implementation
MeSH Terms: Cardiovascular Diseases, Evaluation Studies